Aetna Failed to Provide a Full and Fair Review of Louisiana Banking Manager's Claim for Disability Benefits

A Louisiana federal court ruled that Aetna Life Insurance Company (“Aetna”) failed to substantially comply with the Employee Retirement Income Security Act (“ERISA”) when it terminated a Capital One Resource Manager’s disability benefits.

Ms. Bertucci and her Claim for Long-Term Disability (“LTD”) Benefits

After struggling with a decades-long history of back pain and several surgeries, Ms. Bertucci was forced to stop working in August 2011 and file a claim for disability benefits. Aetna approved her LTD claim after finding that she was unable to perform the material duties of her own occupation.

Under Ms. Bertucci’s LTD policy, she is still considered disabled after receiving 24 months of benefits only if she is unable to work at “any reasonable occupation.” In October 2014, Aetna terminated Ms. Bertucci’s benefits because it determined that she was capable of working in a variety of sedentary “reasonable occupations” it listed in its denial letter.

Ms. Bertucci appealed Aetna’s termination and argued that its decision was wrong because her medical records and treating doctors’ opinions proved that she was unable to sit long enough to perform sedentary work. She also argued that she did not have the licenses required for the jobs listed in Aetna’s denial letter. In support of her appeal, Ms. Bertucci provided Aetna with a supporting letter from her physician, a vocational evaluation report, and an affidavit describing the chronic pain she experiences.

Aetna denied Ms. Bertucci’s appeal and listed two different sedentary jobs it believed she could perform. Ms. Bertucci then filed a lawsuit, and Aetna reinstated her benefits following mediation.

Less than two years later, Aetna terminated Ms. Bertucci’s benefits once again based on an independent medical examination (“IME”) it required her to attend. Ms. Bertucci appealed the new denial and submitted a supportive Functional Capacity Evaluation (“FCE”), her Social Security Disability Income (“SSDI”) approval notice, and a letter from her doctor disagreeing with Aetna’s IME report.

Aetna denied Ms. Bertucci’s appeal on the grounds that, based on the documentation provided, she “does not appear to have clearly defined functional impairments from sedentary occupation.” Ms. Bertucci then filed another lawsuit against Aetna.

The Court’s Decision

Reviewing the case under an abuse of discretion standard, the court found that Aetna failed to substantially comply with ERISA claim regulations because:

  • Aetna identified new occupations it believed Ms. Bertucci could perform without providing her with an opportunity to challenge this new rationale; and
  • Aetna must address Ms. Bertucci’s argument that the new occupations it identified involve starting salaries well in excess of any amount she has ever made and are not reasonable occupations for someone in her late fifties, who has been out of the workforce for seven years, who has no experience in similar roles, and who is restricted from sitting for prolonged periods of time.

Therefore, the court ordered Aetna to go back and provide Ms. Bertucci with a full and fair review of her claim.

Help from an Attorney with Expertise in Disability Insurance

Disability insurance law is complicated. If your claim for long term disability benefits was denied or being delayed by an insurance company, it is important to get help from a lawyer with expertise in disability law.

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